Healthcare professionals must do much more than care for patients in order to provide patient care. They also need to be part-time administrators, charting the care that has been provided so as to create a complete patient record so that they and other providers may know what treatments the patient has received, and to know which drugs the patient is taking (to prevent harmful drug interactions), for example. They also need to enter information needed for billing purposes, so that their employer can be reimbursed for the care they provide. Sometimes, physicians may spent large portions of their day writing in charts and the like, or may employ transcription services to convert their voice recordings into relevant textual information, and then employ other staff to get that information connected to the appropriate records. Each such step adds expense and the chance for errors to the process. Also, paper recordkeeping suffers from limited or lack of access, illegibility, incompleteness, need for storage, and a lack of safety safeguards.
Electronic records, including electronic medical records (EMRs), electronic health records (EHRs), and electronic billing, have simplified the recordkeeping task and made it more powerful. For example, EMRs can be searched electronically to identify patients in need of certain types of care. EMRs may also be analyzed electronically to identify problems with a patient that may not have been apparent to the team caring for the patient. Also, EMRs allow voluminous data to be stored and accessed for a patient, and for the data to be accessed from any location and my multiple different parties at the same time. Many EMR systems, however, simply attempt to emulate the traditional paper chart. by providing users with templates that are populated with selection boxes, drop-down boxes and text boxes for the entry of findings. Such approaches may require numerous time-consuming mouse clicks or screen touches, diminished operator efficiency and operator fatigue.